PrEP, African-Americans and the Future of Prevention

African-Americans remain the population most disproportionately impacted by HIV in the United States. Comprising only 14% of the population in 2009, they accounted for 44% of HIV infections that year. Of the 1.1 million people living with HIV in the United States, 545,000 are African-American. In addition, new HIV infections among young African-American men who have sex with men (MSM) increased by 48% from 2006-2009. This suggests the urgency and critical place we find ourselves in as we grapple with the HIV epidemic in African-American communities that are facing the most severe burden of the epidemic. HIV in the United States will not be eradicated until it's confronted head on in the African-American community.

Over the past three decades there have been a number of key advances in HIV prevention. Condom education for example, has become an institutionalized part of comprehensive sexual health education. We have also seen the overwhelming success of syringe exchange programs as another critical step in reducing HIV infection among injecting drug users. Over the past few years, the advances in biomedical HIV prevention have offered additional hopeful signs in our HIV prevention efforts. Pre-Exposure Prophylaxis or (PrEP), is one of those advances. PrEP is a strategy in which HIV negative people take HIV medicine (antiretrovirals or ARVs) prior to a possible HIV exposure to reduce risk of infection. Using ARVs to decrease the risk of HIV transmission has already been successful in reducing transmission in HIV positive mothers to their infants.

Two recent studies make this point even clearer, demonstrating that PrEP can be both safe and effective. The iPrEx study was a multinational randomized controlled study in 2,499 HIV-negative men who have sex with men (MSM) and transgender women who have sex with men. The Partners PrEP study enrolled 4,758 HIV serodiscordant couples, in which one partner has HIV and the other does not, from nine research sites in Kenya and Uganda. Both studies indicated the safety and efficacy of PrEP within their respective populations.

With the proliferation of information about PrEP, especially as information is disseminated into communities, there has been understandable excitement, caution, and in some cases alarm. The Final Call, the newspaper of the Nation of Islam recently published a story about PrEP and black communities. The article highlighted some of the anxieties and concerns that the introduction of PrEP into our national HIV prevention toolbox might create. Understandably the present relationship and history between researchers and marginalized communities have contributed to some of the ambivalence. Any mention of scientific research and African-Americans is usually coupled with reflections of Tuskegee. Tuskegee refers to the now infamous research conducted from 1932 and 1972 in Tuskegee, Alabama by the U.S. Public Health Service to study syphilis that went untreated in poor black men. The black men in the study thought they were receiving free health care from the government. In the aftermath of Tuskegee there have been a number of precautions taken and policies implemented to ensure the safety and understanding of study participants. There has also been the development of very successful community engagement programs like The Legacy Project. The Legacy Project is an initiative of The Office of HIV/AIDS Network Coordination (HANC), and has sought to remedy the broken relationship with education, and even promote the value of participating and engaging in research to people of color.

Currently, Gilead Sciences Inc. is seeking approval with the US Food and Drug Administration for the HIV drug Truvada to be used as PrEP. And if approved, will present another historical milestone for the history of the HIV epidemic in this country.

Besides effectively engaging communities another challenge is cost. Cost of expensive HIV drugs, staffing support to ensure treatment adherence, and expanded HIV testing and counseling efforts, is a inescapable factor to successful deployment of our HIV prevention toolbox. As government assisted AIDS Drug Assistance Programs (ADAP) waiting lists grow, what does it mean to provide HIV medications to negative people? There are very tough questions we have to struggle with.

The HIV rates among African-Americans indicate that innovation in prevention is not only a scientific necessity, but a moral one. The implications around PrEP and African-American communities is a highly complex issue that must be examined both with rigor and courage. One thing is certain, we need more research into how PrEP operates in a real-world context, particularly within the African-American community. This National Black HIV/AIDS Awareness Day provides us an opportunity to acknowledge the challenges such strategies like PrEP, but also the hope of effectively reducing HIV rates in African-American communities.

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